Responding to NIH’s Helping to End Addiction Long-term (HEAL) initiative NOSI titled “Opioid Use Disorder Care Pathways for Individuals with Histories of Exposure to Violence,” this R61/R33 project seeks to develop and evaluate a brief video and text messaging intervention delivered in the emergency department (ED) to prevent the onset or escalation of opioid use, misuse, or disorder among recent sexual assault (SA) survivors. More than 1 in 4 women will experience an attempted or completed rape in her lifetime. PTSD and opioid misuse are prevalent in the wake of sexual violence, and the opioid epidemic is having a unique impact on women, with sharper increases in prescription opioid deaths, a greater likelihood of meeting criteria for opioid use disorder (OUD), and increased likelihood of comorbid mental health conditions compared to men. ED visits for sexual assault medical forensic exams (SAMFEs) have increased more than 1500% in the last two decades and may provide an important opportunity to intervene to prevent the onset or escalation of PTSD and opioid misuse and disorder. Our team developed and tested a brief video intervention delivered in the ED to women presenting for a SAMFE in two randomized controlled trials. Compared to treatment as usual (TAU), the video was associated with reductions in PTSD, depression, suicidality, alcohol, marijuana, and nicotine use for subgroups of survivors when followed over 6 months. However, in our second RCT, an active control mindfulness video better reduced post-SA opioid use compared to TAU for survivors with pre-SA opioid misuse. Thus, we propose to develop a new video, Skills Training in Active Recovery (STAR) based on the evidence-based principles of both videos to better address PTSD and opioid misuse. In the previous RCTs, survivors reported substantial distress at the SAMFE; given that distress can impair memory encoding, we propose to develop a 3-week daily text messaging program called TextSTAR that will reinforce content presented in the video but give opportunities for survivors to engage with the material in a different setting and over a longer period of time. During the R61, we propose to develop the STAR video and TextSTAR and get feedback from a community advisory board of sexual assault survivors about the wording and presentation of the content to maximize acceptability and utility. We will pilot test STAR and TextSTAR with a separate sample of survivors (N = 50) recruited from 5 ED sites within the Better Tomorrow Network, a research network of SAMFE programs throughout the US, to gather preliminary data about our recruitment approach, acceptability of the intervention, and efficacy. In the R33, we will conduct a SMART trial where survivors will be randomized to receive STAR or no video at the ED, assessed at 1 week, and those above threshold for acute stress/PTSD or opioid use, misuse or disorder will be randomized to receive TextSTAR or no text intervention for 3 weeks. We will re...